Healthcare Provider Details

I. General information

NPI: 1144394164
Provider Name (Legal Business Name): OMAHA SPORTS PHYSICAL THERAPY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 06/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12100 W CENTER RD SUITE 525
OMAHA NE
68144-3969
US

IV. Provider business mailing address

12100 W CENTER RD SUITE 525
OMAHA NE
68144-3969
US

V. Phone/Fax

Practice location:
  • Phone: 402-330-2774
  • Fax: 402-330-2779
Mailing address:
  • Phone: 402-330-2774
  • Fax: 402-330-2779

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name: MR. DAVID H. POTACH
Title or Position: OWNER
Credential: P.T.
Phone: 402-330-2774